Bowel and bladder dysfunction following surgery within the presacral space: an overview of neuroanatomy, function, and dysfunction

Laparoscopic Lateral Suspension (LLS) for Pelvic Organ Prolapse (POP): Update and Systematic Review of Prospective and Randomised Trials

Background: Pelvic organ prolapse (POP) significantly impacts women's quality of life, especially in postmenopausal patients. Although laparoscopic sacrocolpopexy (LSC) is the gold standard for advanced apical prolapse, its complexity and risk of complications have led to alternative approaches like laparoscopic lateral suspension (LLS), a minimally invasive technique with promising results. Methods: A comprehensive search using PubMed databases was performed. The search was conducted from June 2024 to September 2024. The search string used was as follows: (pelvic organ prolapse) AND (lateral suspension) OR (laparoscopic lateral suspension). We included randomized controlled trials, prospective cohort studies, prospective observational studies, and case studies. We excluded retrospective studies, small case series, case reports, and articles not published in English. All selected articles were screened based on the titles and abstracts. Relevant data were extracted and tabulated. Results: An overall number of 12 studies were included in our analysis. LLS demonstrated high anatomical success rates: 91.15% for the anterior, 94.95% for the central, and 86.55% for the posterior compartments. The randomized controlled studies exhibit comparable effectiveness between both methods (LLS vs. LSC) and LLS appears to be the best option for anterior repair or anterior-apical repair. Patient satisfaction rates exceeded 90%, with reduced operative times (123 ± 33 min and 193 ± 55.6 min for ALS and ASC, respectively). According to the Claiven-Dindo scale, 0.17% of postoperative complications were graded more than III. The rate of mesh erosion was 0% to 10%. The technique showed particular benefit for uterine preservation and in obese patients but was less effective for severe posterior prolapse. Conclusions: Laparoscopic lateral suspension offers a safe, effective alternative for POP management, with significant anatomical and functional benefits. Its minimally invasive nature, shorter surgery time, and high satisfaction rates make it suitable for tailored patient care. Further studies should standardize evaluation metrics and assess long-term outcomes. The review was not registered. No funding was received. The authors declare no competing interests.

Presacral Space Surgical Anatomy: Piriformis Fascia as Lateral Border

IMPORTANCE

Safe surgery requires an understanding of the anatomic boundaries and neurovascular structures of the presacral space.

OBJECTIVE

The aim of the study was to characterize anatomy of the presacral space applicable to sacrocolpopexy or rectopexy while highlighting cadaveric findings of the lateral border of the space.

STUDY DESIGN

Structures and boundaries of the presacral space of 18 unembalmed female cadavers were studied. Anatomic relationships and distances to landmarks were established.

RESULTS

A dense connective tissue layer ≤1 mm thick on the piriformis muscle's medial surface attaches to the anterior sacrum just medial to the sacral foramina, separating the lateral sacral vein and sacral nerves laterally from the presacral space contents medially. Median transverse distance from midsacral promontory to right sympathetic trunk was 19.5 (range, 15-31) mm. Distances from right S1, S2, S3, and S4 foramina to midsacral promontory were 28.8 (22-47.5), 48.3 (38.5-72.5), 65.8 (54.5-89.5), and 80.8 (65-104.5) mm and to midline sacrum were 16.5 (14-22), 15.3 (13-20.5), 13.5 (10.5-19.5) and 13.3 (10.5-19.5) mm, respectively. Transverse communicating veins, measuring 3 (2-4) mm in width, penetrated the piriformis fascia, joining the lateral sacral vein to form the sacral venous plexus. Vertical distance from midsacral promontory to the most cephalad communicating vein was 38.3 (7.5-60.5) mm.

CONCLUSIONS

During presacral space surgical procedures, avoiding suture placement and mesh fixation beyond 1.5 cm from the sacrum midline should prevent injury to the sacral sympathetic trunk, sacral nerves, and lateral sacral vein. Transverse communicating vessels of the sacral venous plexus are usually encountered below the S1 foramina level. The piriformis fascia is the lateral boundary of the presacral space over the greater sciatic foramen.

Minimal Invasive Abdominal Sacral Colpopexy and Abdominal Lateral Suspension: A Prospective, Open-Label, Multicenter, Non-Inferiority Trial

BACKGROUND

Abdominal minimally invasive surgery has become increasingly prominent for the treatment of prolapse. Abdominal sacral colpopexy (ASC) is the gold standard for the treatment of advanced apical prolapse; however, alternative surgical approaches such as the abdominal lateral suspension (ALS) have been developed to improve patient outcomes. This study aims to determine whether ALS improves outcomes compared to ASC in multicompartmental prolapse patients.

METHODS

A prospective, open-label, multicenter, non-inferiority trial was conducted in 360 patients who underwent ASC or ALS for the treatment of apical prolapse. The primary outcome was anatomical and symptomatic cure of the apical compartment at 1-year follow-up; secondary outcomes included prolapse recurrence, re-operation rate, and post-operative complications. A 300-patient cohort was subdivided into 200-patients who underwent ALS and 100-patients who underwent ASC. The confidence interval method was used to calculate the p-value of non-inferiority.

RESULTS

At the 12-months follow-up, the objective cure rate of the apical defect was 92% for ALS and 94% for ASC (recurrence rates were 8% and 6%, respectively, and the p-value for non-inferiority was <0.01). The mMesh complication rates were 1% and 2% for ALS and ASC, respectively.

CONCLUSIONS

This study demonstrated that the ALS technique is not inferior to the gold standard ASC for the surgical treatment of apical prolapse.

Sexual function and lower urinary tract symptoms after minimally invasive endorectal pull-through in adolescent males with Hirschsprung disease

BACKGROUND

Effects of colorectal resection on sexual function and the lower urinary tract are inadequately studied in patients with Hirschsprung disease (HD). This study aimed to increase existing knowledge on sexual function and lower urinary tract symptoms (LUTS) in HD male adolescents operated with minimally invasive endorectal pull-through (ERPT).

METHODS

Non-syndromic male adolescents (12-18 years) operated with ERPT were invited to participate in this single-center cross-sectional study which included a semi-structured interview on sexual function and LUTS, a questionnaire recording LUTS, and a urodynamic study. Uroflowmetry curves were eligible for evaluation if the voided volume was >50% of expected bladder capacity. Ethical approval and informed consent were obtained.

RESULTS

Of 37 eligible male adolescents, 35 (95%) with a median age of 14.9 (12.0 -18.3) years were included. 94% had rectosigmoid aganglionosis, and 97% underwent a minimally invasive ERPT. 34 (97%) visited the outpatient clinic. The ability to get erections and to ejaculate was assessed in 25/35 (71%) adolescents. 25/25 (100%) could get an erection, and of adolescents ≥15 years 14/15 (93%) could ejaculate. 32 (91%) returned the questionnaire and underwent urodynamic studies. 15/32 (47%) reported LUTS, but most had only sporadic LUTS. 31/32 (97%) were highly satisfied with their bladder function. Sporadic urinary incontinence was reported by 4/32 (13%), but none reported social problems due to this. Of the eligible 28/32 (88%) uroflowmetry curves, 15/28 (54%) were normal.

CONCLUSIONS

Minimally invasive ERPT seems to preserve sexual function and does not induce lower urinary tract symptoms in adolescent HD males.

LEVEL OF EVIDENCE

III.

Laparoscopic resection rectopexy significantly affects preexisting urinary symptoms in female patients

PURPOSE

It has previously been noted that following rectopexy, some patients report changes in urinary function. So far, not much is known about the extent of such changes. This study assesses the effects of laparoscopic rectopexy on urinary symptoms.

METHODS

Prospective observational study with 100 consecutive female patients indicated for laparoscopic resection rectopexy. Stated urinary symptoms, pre- and postoperative "International Consultation on Incontinence Questionnaire" (ICIQ), supplemented by a "quality of life " (QoL) visual analogue scale, and residual urine measurements (RUM) were compared and correlated.

RESULTS

Postoperative QoL was significantly improved, irrespective of preexisting urinary symptoms. Twenty-four (24%) patients noticed improved urinary function. This corresponded with 42% of 45 patients who had positive preoperative ICIQ scores indicating preexisting urinary symptoms. Conversely, 14 (14%) patients noticed a postoperative increase of urinary complaints. The stated symptom change was only in part reflected by changes of the ICIQ scoring. Comparing ICIQ, 19 (19%) patients scored "better" postoperatively against 8% scoring worse; 5 of the 8 patients experienced "de novo" symptoms. The improved postoperative ICIQ scoring was highly significant. RUM did not sufficiently correlate to symptoms/ICIQ for any meaningful conclusion.

CONCLUSIONS

Laparoscopic resection rectopexy had predominantly beneficial and to a lesser extent detrimental effects on urinary symptoms. Effects were highly significant; they were mainly noted in patients with preexisting urinary complaints. So far, it is not possible to predict such effects on an individual basis. It appears likely that similar effects may be found for most of the alternative operative procedures for the treatment of rectal prolapse. Without more factual knowledge and awareness about the extent of potential "collateral" effects of pelvic floor repair procedures, expert guidance of patients appears limited.

Outcomes of nerve-sparing laparoscopic sacropexy on one hundred fifteen cases

STUDY OBJECTIVE

To evaluate the postoperative anatomic and functional outcomes of patients who underwent laparoscopic nerve-sparing sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse (POP) POP-Q stage III and IV apical prolapse, and to delineate the contributing factors for recurrence.

STUDY DESIGN AND CLASSIFICATION

The file records of patients who underwent sacropexy in the last five years were reviewed retrospectively and compared in terms of preoperative and postoperative anatomic findings and symptoms.

PATIENTS

Patients who underwent laparoscopic nerve-sparing surgery for treatment of POP-Q Stage III and IV/prolapse of uterine or vaginal cuff were included.

INTERVENTIONS

Postoperative anatomic and functional outcomes were evaluated using POP-Q classification and urinary/anal function by questioning during visits.

RESULTS

The mean follow-up duration was 24.2 ± 17.6 months. Anatomic recovery was achieved in 104 (90.4 %) cases. Advanced age (≥70 years), longer duration of symptoms, and low body mass index were determined as parameters related to recurrence risk.

Suspensory Ligaments of the Female Genital Organs: MRI Evaluation with Intraoperative Correlation

The uterus, which plays an important role in the reproductive process, provides a home for the developing fetus and so must be in a stable, though flexible, location. Various structures with suspensory ligaments help provide this berth. MRI with high spatial resolution allows us to detect and evaluate these relatively fine structures. Under physiologic conditions, MRI can be used to depict uterine and ovarian ligaments (ie, the uterosacral, cardinal, and round ligaments, as well as the suspensory ligament of the ovary). In the presence of pathologic conditions (inflammation, endometriosis, tumors), the suspensory ligaments may appear thickened or invaded, which makes their delineation easier. Understanding the normal anatomy of the suspensory ligaments of the female genital organs and using a standardized nomenclature are essential for identifying and reporting related pathologic conditions. The female pelvic anatomy and the suspensory ligaments of the female genital organs are described as depicted with MRI. Also, the compartmental anatomy of the female pelvis is explained, including the extraperitoneal pelvic spaces. Finally, a checklist is provided for structured reporting of the MRI findings in the female pelvis. Online supplemental material is available for this article. ^©RSNA, 2018.

Medium-term outcomes after robotic-assisted lateral suspension with mesh for advanced multi-compartmental prolapse

Introduction and hypothesis

Robotic abdominal lateral suspension (RALS) is an innovative mini-invasive surgical technique that allows treating apical and anterior prolapse. The safety and efficacy of this strategy have not yet been tested.

Methods

We completed a prospective case series of 115 RALS to treat apical and anterior prolapse stage III or IV, with no or minimal (stage I) posterior defect. Clinical evaluation was performed with a simplified POP quantification system (POP-Q). Mean follow-up was 28 ± 4 months. Primary outcomes were objective and subjective cure; secondary outcomes were reoperation rate for recurrence, erosion rate and complications. Objective cure was defined as POP-Q ≤ 1. Subjective cure was defined as absence of vaginal bulge. Patient’s satisfaction was measured using the Patient Global Impression of Improvement Scale (PGI-I).

Results

There was a significant improvement in POP-Q score in all treated compartments with an objective cure rate of 88.7% for the anterior and 93.1% for the apical compartment (p < 0.0001). Subjective cure rate was 82%. The emergence of de novo high rectoceles was not significant in the cohort, as much as the development of de novo stress or urge urinary incontinence. Reoperation rate for POP was 11.3% (8 recurrent cystoceles without apical descent and 5 apical and anterior relapses). No postoperative complications of Clavien-Dindo grade ≥ 3a were seen. Mesh exposure rate was 0.9%; 58.2% patients compiled a PGI-I score at 18–24 months post-surgery, reporting high satisfaction rates.

Conclusions

RALS is highly effective at a mid-term follow-up for the treatment of advanced apical and anterior POP.

Does being performed by urologist or gynecologist affect the outcomes of women who have had sacrocolpopexy?

OBJECTIVE

To compare the outcomes of women who underwent abdominal sacrocolpopexy (ASC) by urologist and gynecologist.

STUDY DESIGN

A total of 61 women underwent transabdominal sacrocolpopexy, with 31 by a urologist (Group 1) and 30 by a gynecologist (Group 2). The patients were presented with symptomatic pelvic organ prolapse (POP). The results were evaluated with Baden-Walker system and International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) to assess anatomical and continence outcomes. Postoperative complications were documented based on the Dindo and Clavien Classification. Statistical analyses were done using Mann-Whitney U test and Fisher's exact test with SPSS version 21.0.

RESULTS

The mean follow-up time was 21.4 (12-36) and 21.8 (12-36) months for Group 1 and Group 2, respectively (p = 0.72). The mean estimated blood loss and length of hospitalization were similar in both groups. The success rates were; 93.5% for Group 1 and 93.3% for Group 2 (p = 0.89). There was no difference in complication rates between the two groups (p > 0.05).

CONCLUSION

The fact that it was administered by gynocologist or urologist does not affect the outcomes of sacrocolpopexy surgery. Similar success and complication rates were found in the patients for both groups.

Laparoscopic pectopexy: a follow-up cyclic biomechanical analysis determining time to functional stability

INTRODUCTION

Pectopexy, a laparoscopic method for prolapse surgery, showed promising results in previous transient testing by this group. It was shown that a single suture, yielding an ultimate load of 35 N, was equivalent to continuous suturing. This was demonstrated in an in vitro cadaver study. This transient data were used to establish an elastic stress-strain envelope. It was now possible to proceed to dynamic in vitro analysis of this surgical method to establish time to functional stability.

METHODS

Cyclic testing of this fixation method was performed on human female embalmed cadaver (cohort 1) and fresh, non-embalmed cadaver (cohort 2) pelvises. The testing envelope was 5-25 N at a speed of 1 mm/s. 100 load regulated cycles were applied.

RESULTS

100 cycles were completed with each model; no overall system failure occurred. Steady state, i.e., functional stability was reached after 14.5 (± 2.9) cycles for the embalmed group and after 19.1 (± 7.2) cycles for the non-embalmed group. This difference was statistically significant p = 0.00025.

CONCLUSION

This trial showed in an in vitro cyclic testing of the pectopexy method that functional stability may be achieved after no more than 19.1 cycles of load exposure. When remaining within the established load envelope of below 25 N, patients do not need to fear global fixation failure. Testing did demonstrate differences in non-embalmed and embalmed cadaver testing. Embalmed cadaver testing tends to underestimate time to steady state by 26.3%.

Nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa)

BACKGROUND

Radical hysterectomy is one of the standard treatments for stage Ia2 to IIa cervical cancer. Bladder dysfunction caused by disruption of the pelvic autonomic nerves is a common complication following standard radical hysterectomy and can affect quality of life significantly. Nerve-sparing radical hysterectomy is a modified radical hysterectomy, developed to permit resection of oncologically relevant tissues surrounding the cervical lesion, while preserving the pelvic autonomic nerves.

OBJECTIVES

To evaluate the benefits and harms of nerve-sparing radical hysterectomy in women with stage Ia2 to IIa cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid (1946 to May week 2, 2018), and Embase via Ovid (1980 to 2018, week 21). We also checked registers of clinical trials, grey literature, reports of conferences, citation lists of included studies, and key textbooks for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the efficacy and safety of nerve-sparing radical hysterectomy compared to standard radical hysterectomy for women with early stage cervical cancer (stage Ia2 to IIa).

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methodology for data collection and analysis. Two review authors independently selected potentially relevant RCTs, extracted data, evaluated risk of bias of the included studies, compared results and resolved disagreements by discussion or consultation with a third review author, and assessed the certainty of evidence.

MAIN RESULTS

We identified 1332 records as a result of the search (excluding duplicates). Of the 26 studies that potentially met the review criteria, we included four studies involving 205 women; most of the trials had unclear risks of bias. We identified one ongoing trial.The analysis of overall survival was not feasible, as there were no deaths reported among women allocated to standard radical hysterectomy. However, there were two deaths in among women allocated to the nerve-sparing technique. None of the included studies reported rates of intermittent self-catheterisation over one month following surgery. We could not analyse the relative effect of the two surgical techniques on quality of life due to inconsistent data reported. Nerve-sparing radical hysterectomy reduced postoperative bladder dysfunctions in terms of a shorter time to postvoid residual volume of urine ≤ 50 mL (mean difference (MD) -13.21 days; 95% confidence interval (CI) -24.02 to -2.41; 111 women; 2 studies; low-certainty evidence) and lower volume of postvoid residual urine measured one month following operation (MD -9.59 days; 95% CI -16.28 to -2.90; 58 women; 2 study; low-certainty evidence). There were no clear differences in terms of perioperative complications (RR 0.55; 95% CI 0.24 to 1.26; 180 women; 3 studies; low-certainty evidence) and disease-free survival (HR 0.63; 95% CI 0.00 to 106.95; 86 women; one study; very low-certainty evidence) between the comparison groups.

AUTHORS' CONCLUSIONS

Nerve-sparing radical hysterectomy may lessen the risk of postoperative bladder dysfunction compared to the standard technique, but the certainty of this evidence is low. The very low-certainty evidence for disease-free survival and lack of information for overall survival indicate that the oncological safety of nerve-sparing radical hysterectomy for women with early stage cervical cancer remains unclear. Further large, high-quality RCTs are required to determine, if clinically meaningful differences of survival exist between these two surgical treatments.

Peri-prostatovesicular smooth muscle tumors of undetermined malignant potential: a case report

INTRODUCTION

Smooth muscle tumors of undetermined malignant potential (STUMPs) are atypical smooth muscle tumors, most of which derived from uterine tissue. STUMPs of male genitourinary system and of the male pelvic organs are uncommon.

CASE DESCRIPTION

In this report, we describe the first case of peri-prostatovesicular STUMP that was treated with laparoscopic excision, in a young asymptomatic man.

CONCLUSIONS

In most cases, the definitive diagnosis can be made only after surgical resection and accurate histological examination. The usefulness of adjuvant chemotherapy remains unclear, and a standardized follow-up protocol has not been described.

Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function

AIM

To compare our developed nerve preserving technique with the non-nerve preserving one in terms of de novo bowel symptoms.

METHODS

Patients affected by symptomatic apical prolapse, admitted to our department and treated by nerve preserving laparoscopic sacropexy (LSP) between October, 2010 and April, 2013 (Group A or “interventional group”) were compared to those treated with the standard LSP, between September, 2007 and December, 2009 (Group B or “control group”). Functional and anatomical data were recorded prospectively at the first clinical review, at 1, 6 mo, and every postsurgical year. Questionnaires were filled in by the patients at each follow-up clinical evaluation.

RESULTS

Forty-three women were enrolled, 25/43 were treated by our nerve preserving technique and 18/43 by the standard one. The data from the interventional group were collected at a similar follow-up (> 18 mo) as those collected for the control group. No cases of de novo bowel dysfunction were observed in group A against 4 cases in group B (P = 0.02). Obstructed defecation syndrome (ODS) was highlighted by an increase in specific questionnaires scores and documented by the anorectal manometry. There were no cases of de novo constipation in the two groups. No major intraoperative complications were reported for our technique and it took no longer than the standard procedure. Apical recurrence and late complications were comparable in the two groups.

CONCLUSION

Our nerve preserving technique seems superior in terms of prevention of de novo bowel dysfunction compared to the standard one and had no major intraoperative complications.

Laparoscopic Nerve-Preserving Sacropexy

STUDY OBJECTIVE

To demonstrate our developed nerve-preserving technique during laparoscopic sacropexy (LSP) for multicompartment pelvic organ prolapse.

DESIGN

A step-by-step demonstration of our surgical procedure on video (Canadian Task Force classification II-2). Informed consent was obtained from the subject, and the applicable Institutional Review Board provided approval.

SETTING

Although sacropexy does remain the 'gold standard' procedure for apical prolapse [1], the subjective outcome of the procedure has been reported to be not so satisfactory as its anatomic outcome [2]. New onset bowel symptoms have been observed with voiding and sexual dysfunctions [3]. Published data revealed a correlation between iatrogenic denervation during LSP and postoperative dysfunctions [4-6]. We adopted a nerve-preserving approach with the aim of reducing the iatrogenic morbidity.

INTERVENTIONS

Our surgical nerve-preserving LSP technique from the promontory down to the right uterosacral ligament and the rectovaginal space proceeds in 3 steps: Step 1: Opening the peritoneum. The peritoneum is opened just medial to the right common iliac artery, approximately 20 to 30 mm above the sacral promontory, allowing a safe approach in an area far from nerves and vascular structures. Peritoneal incision is extended toward the promontory. The underlying presacral fascia containing the right hypogastric nerve (rHN) is identified and incised longitudinally. The presacral fascia and the rHN are then pushed medially to expose the longitudinal anterior vertebral ligament; the finding of the middle sacral veins represents the limit of any further medial dissection. Opening and displacement of the prevertebral fascia are not mandatory. Step 2: Opening the peritoneum of the right pelvic sidewall, respecting the integrity of the presacral fascia and of the rHN contained within it. An inverted L-shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament is completed, with care taken to preserve the rHN identified previously. In proximity to the uterus, the dissection line crosses the upper edge of the right uterosacral ligament at its proximal third and extends medially. The rectovaginal space is opened and joined to the peritoneal tunnel with a section of the superficial layer of the right uterosacral ligament, preserving its deep nervous portion. Step 3: Dissection of the rectovaginal space, respecting the integrity of the rectal fascia. The rectovaginal space is fully dissected, and at its caudal edge the dissection is carried out laterally to the rectum upward to identify the pelvic parietal fascia covering the levator ani muscle, in the middle to the cranial edge of the perineal body. Preservation of the rectal fascia prevents possible injury to the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which runs close to the pelvic floor. The complete dissection of the rectovaginal space appears in an inverted V-shaped space covering approximately two-thirds of the posterior vaginal wall, with the apex at the convergence of the uterosacral ligaments. The procedure is completed with dissection of the vesicovaginal space through the creation of an avascular triangular-shaped space with the apex at the dorsal end of the bladder trigone and laterally limited by the superficial vascular layer of the vesicouterine ligaments. The bladder branches of the inferior hypogastric plexus run far from the surgical field in the deep portion of the vesicouterine ligaments.

CONCLUSION

A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps, which allow the surgeon to visualize all of the nerve pathways and potentially dangerous anatomic structures.

Urological and sexual outcome in patients with Hirschsprung disease: A systematic review

PURPOSE

There is a paucity of recent evidence regarding long-term urological and sexual outcomes following surgery for Hirschsprung disease (HD). We aimed to undertake a systematic review of all HD literature to define these outcomes.

MATERIALS AND METHODS

A systematic literature search was conducted on studies from 1966 to 2014. Relevant articles were assessed for urological/sexual operative complications and functional sequelae. Studies were analysed in qualitative (Rangel score) and quantitative syntheses.

RESULTS

Initially 257 reports were assessed, with 24 studies were eligible for inclusion (1972-2014). Mean study quality was 16.5 ± SD 4.8 (range 6-23), indicating overall fair/poor quality. Ten studies (1021 patients) reported operative complications, with ureteric/urethral/vaginal injury occurring in seven (0.7%) patients. In three studies, the primary outcome was urological functional assessment. From 17 studies, 52/2546 patients (2.0%) had reported urinary incontinence. In infants, absent spontaneous erections post-operatively was reported in 3/203 patients (1.5%, 5 studies); of these 3, parents did not note spontaneous erections pre-operatively either. In older patients, erectile dysfunction occurred in 6/498 (1.2%) males. Other sexual outcomes were reported in 10 studies, with 5/10 studies (416 patients) reporting no erectile dysfunction. In the other studies reports ranged from non-specified sexual dysfunction in one study to diverse sexual related problems in nine (7.8%) of their patients in another.

CONCLUSIONS

Urological/sexual outcomes are rarely reported after HD surgery (24 studies over 42 years). Study quality is usually poor and a large proportion of the studies are more than 30 years old. In the majority of series it is unclear whether urological and sexual function impairments were not present or if they were not assessed. Prospective reporting of urological/sexual outcome is required, in particular in the era of new surgical techniques/approaches to HD.

Management approach and surgical strategies for retrorectal tumours: a systematic review

AIM

The management strategy for retrorectal tumours is complex. Due to their rarity, few surgeons have expertise in management.

METHOD

A systematic literature review was conducted using the PubMed database. English language publications in the years 2011-2015 that assessed preoperative management, surgical strategies and chemoradiotherapy for presacral tumours were included. Two hundred and fifty-one abstracts were screened of which 88 met the inclusion criteria. After review of the full text, this resulted in a final list of 42 studies eligible for review.

RESULTS

In all, 932 patients (63.2% female, 36.8% male; P < 0.01) with a retrorectal tumour were identified. Most were benign (65.9% vs. 33.7%, P < 0.01). Imaging distinguished benign from malignant lesions in 88.1% of cases; preoperative biopsy was superior to imaging in providing an accurate definitive diagnosis (91.3% vs. 61.4%, P < 0.05) with negligible seeding risk. Biopsy should be performed in solid tumours. It is useful in guiding neoadjuvant therapy for gastrointestinal stromal tumours, sarcomas and desmoid type fibromatosis and may alter the management strategy in cases of diffuse large B-cell lymphoma and metastases. Biopsies for cystic lesions are not recommended. The gold standard in imaging is MRI. The posterior Kraske procedure is the most common surgical approach. Overall, the reported recurrence rate was 19.7%.

CONCLUSION

This review evaluated the management strategies for retrorectal tumours. A preoperative biopsy should be performed for solid tumours. MRI is the most useful imaging modality. Surgery is the mainstay of treatment. There is limited information on robotic surgery, single-port surgery, transanal endoscopic microsurgery, chemoradiotherapy and reconstruction.

Laparoscopic Pectopexy: A Biomechanical Analysis

Introduction

Pectopexy, a laparoscopic method for prolapse surgery, showed promising results in recent literature. Further improving this approach by reducing surgical time may decrease complication rates and patient morbidity. Since laparoscopic suturing is a time consuming task, we propose a single suture /mesh ileo-pectineal ligament fixation as opposed to the commonly used continues approach.

Methods

Evaluation was performed on human non-embalmed, fresh cadaver pelves. A total of 33 trials was performed. Eight female pelves with an average age of 75, were used. This resulted in 16 available ligaments. Recorded parameters were ultimate load, displacement at failure and stiffness.

Results

The ultimate load for the mesh + simplified single “interrupted” suture (MIS) group was 35 (± 12) N and 48 (± 7) N for the mesh + continuous suture (MCS) group. There was no significant difference in the ultimate load between both groups (p> 0.05). This was also true for displacement at failure measured at 37 (± 12) mm and 36 (±5) mm respectively. There was also no significant difference in stiffness and failure modes.

Conclusion

Given the data above we must conclude that a continuous suture is not necessary in laparoscopic mesh / ileo-pectineal ligament fixation during pectopexy. Ultimate load and displacement at failure results clearly indicate that a single suture is not inferior to a continuous approach. The use of two single sutures may improve ligamental fixation. However, overall stability should not benefit since the surgical mesh remains the limiting factor.